By Shara Yurkiewicz
December 7, 2012
“You’re not sorry.”
Within two days two different patients said this to me,
each with hatred in his voice. Each time I was alone,
each time I had known the patient for only a few
minutes, and each time the rage was directed at me and
For seven months, I had avoided being the bad guy.
When a patient got upset, he accused my superiors, and
I hid behind their authority with relief. With no
power came no blame. I would offer sympathetic eyes
during the blow-outs and weigh how much of what the
patient perceived was in line with reality.
The last two episodes were on an entirely different
level, not because of their intensity but because no
one but me stood there to shoulder them. Now I see
patients alone and project a greater air of confidence,
which naturally leads some to believe that I am the one
making their decisions. My usual intellectualization
and analysis were non-existent; I experienced a pure
The first episode, in retrospect, was merely a
preamble. I walked into the clinic room and was
greeted with “You’re 45 minutes late.” I apologized.
The patient insisted I wasn’t sorry but that I was
unprofessional. I don’t quite remember all the
personal attacks he added over the next few minutes
because my sympathetic system had taken over: my cheeks
flushed, my heart pounded, and all I wanted to do was
I managed to squeeze out that we were running behind
because we spent more time with sicker patients than we
had anticipated. What I wanted to add was that he was
setting us more behind. What I wanted to add was that
even though his appointment was only for 20 minutes, we
would spend more than 20 minutes with him, like we did
for every patient. What I wanted to add was that his
behavior was self-fulfilling: suddenly I wasn’t sorry
Instead, I withdrew. I’m fairly certain I took a less
thorough history with him than I do with other
patients. I’m pretty sure my plan was more rushed
since he questioned my judgment at several junctures.
I know that all I wanted to do was get out of that room
and away from an unpleasant person that I had
originally wanted to help to the best of my ability
until he compromised my ability to help him.
Two days later, I was back in the hospital with a much
sicker patient. I walked in to do a physical exam and
the patient demanded that I get him food. I explained
that he couldn’t eat independently because he was at
severe risk for swallowing the wrong way and having the
food go into his lungs and causing an infection.
“You f*cking b*tch,” the patient yelled as loudly as he
could with his weakened voice as he tried and failed to
get out of bed and reach his food. I apologized and
once again I heard the cutting response: “You’re not
Again, I felt the familiar flushing as the patient
called me creative names and instructed me to do
creative things. This time, I had no response at all.
After the first minute, I felt sorry that the patient
was hungry and couldn’t eat. I felt sorry that he had
such poor hand dexterity that he needed someone else to
feed him. I felt sorry that he didn’t deserve the
medical hand he had been dealt.
After several minutes though, my empathy faltered and
finally gave out. My thoughts turned from the
patient’s plight to a more inward stance: I don’t
deserve this. That single thought amplified until the
hungry patient in front of me no longer existed. I
don’t deserve this. I knew it wasn’t personal because
he would have screamed at anyone who happened to stand
in my place. But at the same time it was personal
because it happened to be me.
I didn’t say much and walked out, feeling shaky. More
disturbing thoughts snaked their way into my
consciousness and wouldn’t let go. No, I wasn’t sorry
anymore. No, I didn’t really care what happened to
him. And then probably the worst thought I’ve ever had
in my life: in that moment, I didn’t really care if he
lived or died.
With that realization, I found a bathroom to cry in for
about half an hour while I ignored the page from my
resident inviting me to get lunch.
Within an hour, my limbic brain had yielded to my
cortex and I was able to analyze what had happened.
Ironically, it was the analysis rather than my raw
emotion that brought back empathy. I reread the
patient’s notes, talked to his son, and felt as though
I had a better grasp on the reasons behind his intense
Within a few hours, the patient was transferred to the
ICU. (Thankfully, the turn of events was unrelated to
the care I did or did not give him.) Half of me felt
sorry but the other half still felt relieved that I
would not have to see him again.
During our psychiatry rotation, we had had a lecture on
how to think about “difficult” patients. We were
encouraged to think about the feelings of helplessness,
uncertainty, anxiety, and fear patients felt, in
addition to the destructive medical processes impairing
their minds and bodies. We were told never to forget
that context when we dealt with someone whose behavior
didn’t conform to our expectations of how a “good”
patient should act. It was a very valuable lecture,
and I sat in the safety of our conference room
On the floor, feeling vulnerable and alone, feeling
attacked and helpless, I lost sight of that lecture. I
was feeling the same things my patient most likely
felt, yet to a fraction of an extent. Although I
didn’t verbally abuse anyone the way he did, my
internal verbalizations were probably just as abusive.
Destruction need not be loud and it need not be an
action. Perhaps it begins with a thought, one that
snakes into your consciousness and amplifies. Perhaps
it ends in inaction, with you walking out of the room
On the first episode of Scrubs, one of J.D.’s first
patients passes away suddenly from a pulmonary
embolism. He narrates. ”I’ll never forget that
moment. The way he looked exactly the same only
completely different. The shame that all I could think
about was how hard this was for me.” Seven months
after I have started this thing called hospital
medicine, I have finally felt that shame.
Before I wrote this post, I checked on that patient’s
status. He had recently passed away. I hadn’t known.
It hadn’t been an expected event.
I wonder if I had known how close he was to death if my
thoughts of him would have changed in that moment when
our lives intersected.
I also know that the answer shouldn’t matter.
Here’s to the start of being the bad guy with good
intentions. Here’s to the start of trying harder, of
keeping those good intentions during the most difficult
moments–those when no one else believes you have them.
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